NOSE Scale: Nasal Blockage and CPAP

The NOSE (Nasal Obstruction Symptom Evaluation) scale is a five-question survey that scores how much a blocked nose bothers you, from 0 (no problem) to 100 (the worst). A 2013 study classed scores as mild (5 to 25), moderate (30 to 50), severe (55 to 75) or extreme (80 to 100), and found 30 best separated people with and without nasal obstruction (Lipan and Most, 2013). For CPAP users, it turns "my nose is always blocked" into a number to discuss. Take the NOSE scale here.

Who Made the NOSE Scale

The NOSE scale was developed by Michael Stewart and colleagues at four US academic medical centers and published in 2004 in Otolaryngology, Head and Neck Surgery (abstract on PubMed (opens in new tab)). It was built for adults with nasal obstruction, and its validation study enrolled 32 adults with nasal septal deformity (such as a deviated septum). The authors reported test-retest reliability of 0.702 and internal consistency of 0.785, which they judged adequate, and found the scale sensitive to change after treatment.

The study was funded by the American Academy of Otolaryngology, Head and Neck Surgery Foundation. The Foundation offers the scale free: "If others wish to use the tool, there is no cost, we simply ask that you reference the study." We do, on the tool page and under every result.

The Five Questions

The NOSE scale asks how much of a problem five things have been over the past month: nasal congestion or stuffiness, nasal blockage or obstruction, trouble breathing through the nose, trouble sleeping, and not being able to get enough air through the nose during exercise or exertion.

Each answer runs on a five-step scale from "not a problem" (0) to "severe problem" (4). Four of the five questions are about the nose itself; one, trouble sleeping, is about what a blocked nose does to your night.

How the Score Is Calculated

Add the five answers for a total from 0 to 20, then multiply by 5. That gives a score from 0 to 100, always in steps of 5. Higher means worse symptoms.

A few examples:

All five answered "not a problem" gives 0.
Two answers of "moderate problem" (2 each), two of "very mild problem" (1 each) and one "not a problem" gives 6, times 5, which is 30.
All five answered "severe problem" gives 20, times 5, which is 100.

What the Severity Classes Mean

The original paper did not set severity bands. In 2013, Lipan and Most at Stanford looked at NOSE scores from 345 patients seen at a university clinic between July 2011 and May 2012, and proposed four classes (abstract on PubMed (opens in new tab)).

Score	Class
5 to 25	Mild
30 to 50	Moderate
55 to 75	Severe
80 to 100	Extreme

A score of 0 sits outside the classes: no symptoms were reported. In their data, a score of 30 best separated patients with nasal obstruction from those without, which is why the moderate class starts there.

The classes describe how much the symptoms bother you. They do not tell you the cause. A deviated septum, allergies, swollen tissue inside the nose (the turbinates), polyps and a cold can all produce the same score. Finding the cause is a job for your doctor or an ear, nose and throat specialist (ENT).

Why a Blocked Nose Matters for CPAP

Nasal masks and nasal pillows send pressurized air in through the nose. When the nose is blocked, that path is harder to use. Some people end up breathing through the mouth, which can let air escape (a mouth leak), dry out the mouth and throat, and make the mask feel like it is not working. Our guide to CPAP dry mouth and nose covers what people commonly review with their provider.

That is why the NOSE score is useful before a mask conversation. It gives you and your provider a number, measured the same way each time, instead of a vague "my nose is stuffy." Things people commonly discuss with their provider when the nose is the problem include:

Mask style. A full face mask covers the nose and mouth, so it does not depend on breathing through the nose. Our comparison of full face and nasal masks explains the trade-offs, and the mask finder quiz asks about congestion too.
Humidity. Heated humidification is a setting your provider can help you review. See our guide to CPAP humidity settings.
The cause of the blockage. An ENT can look for structural causes such as a deviated septum, and your doctor can look at allergies and medications.

Do not change your therapy settings on your own. Bring your NOSE score and your CPAP data to your sleep physician or the clinician who fitted your mask.

Using the Score Over Time

Because the NOSE scale was designed to measure change, it works well as a before-and-after check. Take it before a change (a new mask, allergy treatment, a referral to an ENT) and again a few weeks later. Scores move in steps of 5, so a small change may be just a shift in one answer. A move from one class to another is easier to talk about.

If you use CPAP, your machine's own data adds the other half. A falling NOSE score alongside lower leak or longer usage nights tells a clearer story than either alone. You can import your SD card into CPAP Clarity to see leak and usage night by night.

When to Talk to Your Doctor

Talk to your doctor if nasal blockage has lasted for weeks, is getting worse, comes with nosebleeds, facial pain or swelling, or is affecting your sleep or your CPAP use. A NOSE score in the moderate class or above (30 or more) is a reasonable point to ask whether an ENT referral makes sense.

Frequently Asked Questions

What is a normal NOSE score?

A score of 0 means no nasal symptoms were reported. The Lipan and Most classes call 5 to 25 mild, 30 to 50 moderate, 55 to 75 severe and 80 to 100 extreme. In their data, 30 best separated people with and without nasal obstruction.

How is the NOSE score calculated?

Each of the five answers scores 0 to 4. Add them for a total from 0 to 20 and multiply by 5, for a score from 0 to 100.

Can a blocked nose cause problems with CPAP?

It can. Nasal masks and nasal pillows depend on air moving through the nose, so a blocked nose can lead to mouth breathing, leaks and a dry mouth. Mask style and humidity are both worth discussing with your provider.

Primary Sources

Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004;130(2):157-163. PubMed (opens in new tab)
Lipan MJ, Most SP. Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg. 2013;15(5):358-361. PubMed (opens in new tab)
American Academy of Otolaryngology, Head and Neck Surgery. Facial Plastics/Rhinology Outcome Tool: NOSE Scale (opens in new tab)